Eagle Pointe Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 1600 27th Street, Parkersburg, West Virginia 26101
- CMS Provider Number
- 515159
- Inspections on file
- 22
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Eagle Pointe Healthcare Center during CMS and state inspections, most recent first.
The facility did not consistently serve meals at the posted times, with observations showing residents in the Memory Care unit becoming agitated due to delayed dinner service. Staff interviews and record reviews confirmed that meal trays were frequently served late, with several instances of meals being delivered thirty minutes or more past the scheduled time.
Surveyors found that kitchen staff stacked wet baking pans (wet nesting) and stored dishes, saucers, and coffee pots that were still dirty. A dietary staff member confirmed these issues during an interview. These unsanitary practices had the potential to affect a significant number of residents.
Grievance forms were not readily accessible to residents and could not be filed anonymously, as forms were kept at the nurses' station and required residents to request them from staff and submit them to the Social Worker's office. Facility leadership confirmed these limitations, resulting in a failure to ensure residents' rights to file grievances without reprisal or discrimination.
Staff responsible for admissions were unable to accurately explain the Binding Arbitration Agreement to residents or their representatives, including important details about the arbitration process and legal rights. Many residents or their representatives signed the agreement without a clear explanation, and staff admitted to lacking familiarity with the document.
The facility did not have a certified Infection Preventionist (IP) attend or participate in required QAA meetings, as the DON signed for both roles without evidence of IP certification or part-time work in that capacity. This failure meant not all required committee members were present, potentially affecting all residents.
Two residents were not served meals according to the prescribed menu, with one receiving a hot dog on sandwich bread without condiments and another receiving a hot dog on bread with cheese instead of a bun. Staff confirmed the deviations, and the ADON acknowledged the shortage of buns, indicating that menu requirements were not consistently met.
A lunch tray served to a resident was found to have food items, including buttered noodles and broccoli, at temperatures below the standard for safe and appetizing service. The issue was confirmed by the Regional Dietary Manager during a random check, with the potential to affect many residents.
Surveyors found that food items throughout the facility, including the kitchen, dining areas, dementia unit, and nourishment pantries, were not consistently labeled, dated, or properly sealed after opening. Drinks were left unlabeled and not on ice, and some food items were past their use-by dates. Staff confirmed these deficiencies, and food utensils were not stored according to policy.
A resident was discharged after the end of Medicare Part A skilled services without being provided the required Notice of Medicare Non-Coverage (NOMNC) form. Review of records and staff interview confirmed that the NOMNC was not issued prior to the end of covered services.
A resident who was unable to use her lower limbs was not permitted to use her personal wheelchair, despite being able to self-propel with her arms. Instead, she was placed in a Broda chair that she could not move independently, resulting in unnecessary restriction of her mobility. Therapy staff identified the need for a more suitable chair, but there was a significant delay in obtaining approval for the equipment, leaving the resident dependent on staff for movement.
A resident's care plan was not updated to reflect a new NPO (nothing by mouth) diet order, resulting in outdated interventions such as offering nutrition and allowing pureed snacks. The DON and a corporate RN confirmed the care plan did not match the resident's current dietary status.
A resident with multiple hospitalizations did not receive timely speech therapy screening or evaluation after readmission, as required by facility policy. Although OT and PT completed interdisciplinary screens, no ST recommendations were made, and the resident's care plan was not updated to reflect the current NPO order, resulting in conflicting documentation about oral intake. The DON confirmed the care plan was inaccurate and that the resident had not eaten.
A resident's medical record was incomplete because the required signature on the POST form was not obtained after verbal consent was given by the legal representative, and there was no documented follow-up by the facility to secure the written consent.
Staff did not follow Enhanced Barrier Precautions when providing catheter care to a resident with a Foley catheter. An LPN and a nursing assistant performed high-contact care activities, including perineal and catheter cleaning and changing briefs, while wearing only gloves and not the required gowns, despite posted EBP guidelines.
A bed remote control with exposed electrical wiring, covered with electrical tape, was identified in a resident's room. Staff and the Maintenance Director confirmed the issue, and the Administrator acknowledged the finding during the survey exit.
Surveyors found that the facility did not maintain comfortable temperatures in resident rooms and a common area, with temperatures recorded as low as 65-67°F. A resident was observed bundled in a blanket, and another reported feeling cold to an LPN, who provided a blanket in response.
A resident with multiple chronic conditions, including CHF and COPD, experienced significant weight gain, worsening edema, and shortness of breath over a two-week period. Despite repeated nursing documentation of these symptoms, the facility did not promptly notify the physician or obtain new orders to address the changes. The delay in medical intervention led to the resident's transfer and hospital admission for weight gain, edema, and CHF.
A resident with multiple chronic conditions experienced a delay in necessary medical treatment due to staff failing to recognize and report significant weight gain and +3 pitting edema, as well as not following a physician's order for an outside appointment. Despite ongoing symptoms and care plan instructions to report abnormal findings, the physician was not notified, and the resident was ultimately hospitalized for edema and CHF.
Multiple complaints and observations revealed that residents were served meals that were unpalatable, unattractive, and not at the correct temperature, with issues such as tough meat, overcooked eggs, missing menu items, and late meal service. Test trays and direct observation confirmed that food was not prepared according to recipes, and substitutions were made without proper planning, affecting all residents receiving nutrition from the kitchen.
The facility did not consistently serve meals at scheduled times, resulting in late meal delivery and food that was not palatable or at the correct temperature. Multiple residents and staff reported ongoing issues with meal timing and food quality, and no mealtimes were posted in the facility. The Administrator confirmed the inconsistency in meal service and acknowledged recent changes to meal cart schedules.
A resident with multiple chronic conditions experienced ongoing symptoms and had an order to visit her primary care physician, but the facility failed to assist with transportation, resulting in a canceled appointment. The resident's family attempted to arrange alternative transport, but was unsuccessful, leading to a 911 call and subsequent transfer to the ER. The DON stated the facility did not encourage outside PCP visits despite a physician's order, and the LPN was unaware of the order. This resulted in a failure to support the resident's right to self-determination.
Inconsistent Meal Service Times
Penalty
Summary
The facility failed to serve meals at consistent times in accordance with residents' needs, preferences, and posted schedules. Record review showed that dinner service on the Memory Care unit was scheduled to begin at 5:00 PM, but observation revealed that residents became agitated and restless as dinner was not served until 5:21 PM, twenty-one minutes after the posted time. An interview with a Nurse Aide confirmed that meal service is often late and has been delayed even longer in the past. Further review of thirty-three trayline meal service records indicated that eight meals were served at least thirty minutes or more past the posted dinner time. These findings demonstrate a pattern of inconsistent meal service times, potentially affecting a minimal number of residents.
Unsanitary Storage and Cleaning of Kitchenware
Penalty
Summary
Surveyors observed that kitchen staff failed to store baking pans in a sanitary manner by stacking them while still wet, a practice known as wet nesting. Additionally, plates, saucers, and coffee pots on the clean side were found to be dirty, indicating that dishes were not free from dried substances and were not stored clean. During an interview, a dietary staff member confirmed both the wet stacking of pans and the presence of dirty dishes, acknowledging the issues when pointed out. These practices were directly observed and confirmed, and had the potential to affect more than a minimal number of residents, with a facility census of 119 at the time of the survey. No specific residents or their medical histories were mentioned in the report, and the deficiency was based on direct observation and staff interview regarding food-contact surface sanitation in the kitchen.
Grievance Forms Not Readily Accessible or Anonymous
Penalty
Summary
The facility failed to ensure that residents could fully exercise their right to file grievances, including the ability to file grievances anonymously. During an observation, it was found that grievance forms were not readily accessible to residents, as they were kept at the nurses' station rather than in a location easily accessible to all residents. Interviews with a resident and the Director of Social Services revealed that residents were aware of the grievance policy but needed to request a form from staff and submit it to the Social Worker's office, limiting anonymity. The Administrator and Regional Director of Clinical Operations confirmed that grievance forms were not readily available and could not be filed anonymously, indicating a lack of compliance with grievance policy requirements.
Failure to Clearly Explain Binding Arbitration Agreement
Penalty
Summary
The facility failed to accurately explain the Binding Arbitration Agreement to residents or their representatives in a manner they could understand. Record review showed that 81 residents or their representatives signed and accepted the agreement, while 15 declined. During interviews, both the Back-Up Admission Coordinator and the Admission Coordinator were unable to accurately explain key aspects of the agreement, such as the process for choosing arbitrators and whether residents could pursue issues in court after arbitration. The Admission Coordinator also admitted to not being familiar with the agreement and noted that residents typically do not ask questions about the form.
Certified Infection Preventionist Absent from QAA Meetings
Penalty
Summary
The facility failed to ensure that a certified Infection Preventionist (IP) attended and participated in the Quality Assessment and Assurance (QAA) meetings as required. According to the facility's QAPI policy, the QAA committee must include the Executive Director, Director of Nursing (DON), Medical Director, Infection Preventionist, and three other staff members, with all members present at monthly meetings. Review of QAA meeting agendas and minutes for the quarter from October to December 2024 showed that the IP did not attend any of the meetings. Instead, the DON signed as both the DON and the IP, but the facility could not provide evidence that the DON was officially certified as an IP or working in that role beyond her regular duties as DON. During an interview, the Executive Director confirmed that the facility lacked documentation to verify the DON's certification as an IP and acknowledged that not all required members attended the QAPI meetings. This deficiency had the potential to affect all 108 residents residing in the facility, as the absence of a certified IP in QAA meetings could impact infection prevention oversight. No additional information was provided prior to the end of the survey.
Failure to Follow Prescribed Menus During Meal Service
Penalty
Summary
The facility failed to follow prescribed menus for two residents during meal service. One resident was served a hot dog on a flat piece of sandwich bread without the required condiments, despite the tray card specifying an all-beef hot dog on a bun with mustard. A nursing assistant confirmed that the resident typically eats a hot dog daily and did not receive the correct bread or condiment. Another resident, who had ordered a hot dog, received it on a slice of bread with cheese instead of a bun and expressed dissatisfaction when informed by the aide that hot dog buns had run out. The Assistant Director of Nursing was present and acknowledged the lack of buns but did not provide further explanation at the time. These incidents were identified through record review, observation, and staff and resident interviews, demonstrating that the facility did not ensure menus were followed as required, potentially affecting more than a limited number of residents.
Failure to Serve Food at Appetizing and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at an appetizing and safe temperature, as observed during a random check. On 07/07/2025 at 1:15 PM, the Regional Dietary Manager tested the temperature of a lunch tray that was the last to be served on D Hall. The tray had been on the hall since 1:05 PM. The measured temperatures were 125.1°F for bruschetta chicken, 112.0°F for buttered noodles, and 102.9°F for broccoli. The Regional Dietary Manager confirmed that the buttered noodles and broccoli were below the standard serving temperature. This deficiency had the potential to affect more than a limited number of residents, with a facility census of 108 at the time of the survey.
Deficient Food Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple instances where food items were not stored according to professional standards and facility policy. In the main kitchen and dining areas, several opened food items, such as dry milk, tortillas, cereals, bread, ground turkey, deli ham, sauces, and dressings, were found without proper labeling, dating, or sealing. Additionally, pitchers of drinks in the dining room were not labeled, dated, or kept on ice. The employee refrigerator lacked a lock, and some food items were past their use-by dates. These findings were confirmed by dietary management staff. Further deficiencies were identified in the dementia unit's refrigerator/freezer and nourishment pantries. Opened ice cream, sandwiches, and beverages were not labeled or dated, and some sandwiches were not properly sealed. Snack baskets and other food items in the nourishment pantries were also found without open or use-by dates, and some items were not sealed. Food serving and preparation utensils were stored in drawers with handles not facing the same direction, contrary to facility policy. These issues were confirmed by nursing assistants and LPNs present during the survey.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) form to a resident who was discharged following the end of their Medicare Part A skilled services. Record review showed that the resident's Minimum Data Set (MDS) Discharge assessment was marked as planned, but there was no documentation that the NOMNC was issued prior to the termination of skilled services. During staff interview, the Social Worker Designee confirmed that the NOMNC was not given to the resident or their representative.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
A deficiency occurred when a resident was not allowed to use her personal wheelchair, despite her expressed desire and ability to self-propel using her arms. The resident, who is unable to stand or use her lower limbs, reported that she had previously been mobile in her wheelchair before admission to the facility. Instead, she was provided with a Broda chair, which she could not move independently due to her inability to use her feet. Both the resident and her spouse questioned the restriction, as the resident was capable of upper body mobility. Review of the resident's medical records showed conflicting physician orders regarding her mobility and use of a wheelchair. Occupational therapy documentation indicated that the resident attempted to use a standard wheelchair but slid out of it, leading to recommendations for continued use of the Broda chair for safety. However, the Broda chair provided did not allow for independent movement, and the resident remained dependent on staff for mobility. The therapy team identified the need for a Broda chair with larger wheels that the resident could propel with her arms, and a requisition for this equipment was submitted, but not promptly authorized. The delay in obtaining appropriate seating equipment resulted in the resident being unnecessarily restricted in her movement for an extended period. The resident remained either in bed or in a Broda chair she could not move, despite her stated goal and ability to self-propel with her arms. The lack of timely action to provide suitable mobility equipment led to the use of a device that unnecessarily limited the resident's freedom of movement.
Failure to Update Care Plan Following Change to NPO Diet Status
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect a change in diet status. Medical record review showed that the resident had a current diet order of NPO (nothing by mouth) for diet type, texture, and consistency. However, the resident's care plan still included interventions such as providing a lid on hot beverages, offering nutrition and hydration during checks, and allowing caregivers or family to feed pureed foods as snacks. During staff interviews, the DON confirmed that the care plan was inaccurate and that the resident had not eaten anything, while a corporate RN acknowledged the care plan issue. This discrepancy between the resident's current NPO status and the interventions listed in the care plan demonstrates a failure to update the care plan following a significant change in the resident's dietary needs.
Failure to Provide Timely and Accurate Rehabilitative Services and Care Plan Updates
Penalty
Summary
The facility failed to provide patient-centered rehabilitative services for a resident who had experienced multiple hospitalizations and was readmitted to the facility. Despite the facility's policy requiring interdisciplinary screening for all therapy disciplines upon admission or readmission, speech therapy (ST) was not initiated or screened during the resident's stay or after changes in condition following hospitalization. The Director of Rehabilitation Services indicated that ST was only identified if requested by nursing or other therapies, and noted that speech therapy staff had not been available for some time. Although occupational therapy (OT) and physical therapy (PT) completed interdisciplinary screens, no ST recommendations were made, and the required screening process was not followed as per facility policy. A speech therapy evaluation was eventually completed, resulting in a recommendation for the resident to remain NPO (nothing by mouth), with specific instructions for pleasure feeding and safe swallowing practices. However, the resident's care plan was not updated to reflect the current NPO order and continued to document oral intake with pureed foods, which conflicted with the most recent recommendations. The Director of Nursing confirmed the care plan was inaccurate and that the resident had not consumed any food. No instrumental swallowing studies were completed, and the lack of timely and accurate therapy screening and care plan updates led to the deficiency.
Incomplete POST Form Due to Missing Signature
Penalty
Summary
The facility failed to maintain a complete medical record for one resident by not obtaining a required signature on the Physician Orders for Scope of Treatment (POST) form. Although verbal consent was provided by the resident's legal representative on 04/16/2025, there was no signed consent documented in the medical record. Additionally, there was no evidence that the facility attempted to follow up with the legal representative to secure the necessary written signature, as required by accepted professional standards.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to adhere to infection control protocols while providing care to a resident under Enhanced Barrier Precautions (EBP). The resident, who had a Foley catheter due to bladder incontinence and was alert with a BIMS score of 8, was observed receiving catheter care from an LPN and a nursing assistant. Despite clear signage outside the resident's room specifying that gloves and gowns must be worn for high-contact care activities, including catheter care and changing briefs, both staff members only donned gloves and did not wear gowns during the procedure. During the observed care, the staff entered the room, pulled the privacy curtain, and proceeded to remove the resident's brief, clean the perineum and catheter, and apply a new brief, all without donning gowns or changing gloves. The soiled linens were disposed of appropriately, but the required PPE protocol was not followed. The unit manager confirmed that EBP protocols were not adhered to during this episode of care.
Failure to Maintain Safe Bed Remote Controls
Penalty
Summary
The facility failed to maintain bed remote controls in a safe operating condition for one of five resident beds reviewed. During an interview, an employee confirmed awareness of an issue with a bed remote that had exposed electrical wiring, specifically referencing a bed in room [ROOM NUMBER]B. Subsequent observation by the surveyor revealed electrical tape on the bed control remote for bed 123B. The Maintenance Director later verified the presence of electrical tape on the remote, and this finding was acknowledged by the Administrator during the survey exit. No information was provided regarding the medical history or condition of the resident occupying the affected bed at the time of the deficiency.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
Surveyors observed that the facility failed to maintain resident rooms and common areas at a comfortable temperature, as required for a safe and homelike environment. During a walk-through of the locked Alzheimer's unit, one resident was found tightly bundled in a blanket on his bed, with the room's P-tac unit set to 67 degrees Fahrenheit. Another room's P-tac unit was set to 65 degrees Fahrenheit. Ambient air temperature checks confirmed that one resident room and the TV room were both at 67 degrees Fahrenheit, while another resident room was at 72 degrees Fahrenheit. Additionally, a resident was observed expressing feeling cold to an LPN, who responded by offering a blanket. These findings indicate that the facility did not ensure consistent and comfortable room temperatures for residents, as evidenced by both direct observations and resident complaints.
Delayed Physician Notification and Treatment for Resident with CHF and Edema
Penalty
Summary
A resident with a complex medical history, including dementia, major depressive disorder, COPD, congestive heart failure (CHF), seizures, and hypertension, experienced a significant weight gain of over 12 pounds in two months, progressive lower extremity edema (+3 pitting), and ongoing complaints of shortness of breath. Despite these changes, the facility failed to notify the physician of the resident's weight gain and edema in a timely manner, and did not obtain new physician orders to address these symptoms. Nursing documentation showed repeated observations of edema and pain, but there was no evidence that these findings were escalated to the medical provider until the resident's condition worsened. Nursing notes indicated that the resident was experiencing pain, swelling, and difficulty with mobility, and was refusing showers due to discomfort. The nurse practitioner (NP) evaluated the resident for pain and cellulitis, but did not document or address the previously noted +3 pitting edema. The care plan included instructions to monitor for and report symptoms such as edema and dyspnea, but these were not consistently communicated to the physician as required. The resident continued to experience symptoms, including shortness of breath and increased swelling, over a period of two weeks. Eventually, after further complaints of shortness of breath and continued weight gain, the NP ordered additional assessments and increased diuretic therapy. However, delays in addressing the resident's symptoms and failure to promptly notify the physician contributed to the resident being transferred to the hospital, where she was admitted with a diagnosis of weight gain, edema, and CHF. The deficiency centers on the facility's delay in providing necessary medical treatment and failing to follow established protocols for physician notification and intervention.
Delayed Clinical Assessment and Failure to Notify Physician Leads to Hospitalization
Penalty
Summary
A resident with a complex medical history, including dementia, major depressive disorder, COPD, congestive heart failure (CHF), seizures, and hypertension, experienced a delay in necessary medical treatment due to insufficient ongoing clinical assessment and failure to identify changes in condition by facility staff. Nursing documentation noted significant +3 pitting edema in the resident's lower extremities, as well as a weight gain of over 12 pounds within two months. Despite these findings, there was no evidence that the physician was notified of the weight gain or the edema, nor were appropriate orders obtained to address these changes. The nurse practitioner (NP) examined the resident and documented symptoms of cellulitis, including redness, warmth, and weeping skin on both lower extremities, and prescribed antibiotics. However, the NP did not address the previously documented +3 pitting edema or the resident's significant weight gain. Subsequent nursing notes indicated ongoing edema, redness, and resident complaints of shortness of breath, but staff continued to report that vital signs were within normal limits and did not escalate the situation appropriately. The care plan included instructions to observe for and report edema and other symptoms, but there was no documentation that abnormal findings were reported to the medical provider as required. Additionally, a physician's order for the resident to attend an appointment with her primary care physician was not followed, as transportation was not arranged and staff were unaware of the order. The resident ultimately required hospital admission for weight gain, edema, and CHF. The facility's failure to recognize and act upon significant changes in the resident's condition, notify the physician, and follow physician orders contributed to the delay in necessary medical treatment.
Failure to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food to residents, as evidenced by multiple complaints and observations. Resident Council minutes from several months documented concerns such as tough meat, incorrect preparation of eggs, lack of substitutions, meals not matching the menu, and food being served late. Grievance forms further detailed issues with food quality, including roast beef that was too hard to chew and overcooked meat, fish, and eggs. Residents also reported that posted meal times were not adhered to, resulting in late meals. Direct observation and test tray reviews confirmed these deficiencies. On one occasion, the menu listed Salisbury steak, glazed carrots, egg noodles, and a buttered roll, but the carrots lacked glaze, the egg noodles were mushy and unappetizing, and no rolls were provided. Additionally, mashed potatoes were served in place of egg noodles due to insufficient preparation, and the kitchen staff did not follow the recipe for the noodles, steaming them instead of boiling. The Administrator acknowledged these issues, confirming that the kitchen did not prepare enough food items and failed to follow recipes.
Failure to Provide Timely and Palatable Meals
Penalty
Summary
The facility failed to provide meals and snacks at scheduled times in accordance with residents' needs and preferences, resulting in meals being served late and food not being palatable or at the appropriate temperature. Resident Council minutes documented repeated complaints about late meals, cold potatoes, and flat rolls, with residents being told that meals would be late for various reasons and encouraged to ask for snacks. Grievance forms also noted that meals were usually late and that meat, fish, and eggs were overcooked and tough. Staff interviews confirmed concerns about the lateness and inconsistency of mealtimes, and observations revealed that mealtimes were not posted in the facility. The Administrator acknowledged issues with meal timing and confirmed that mealtimes were not posted, with recent changes to meal cart schedules contributing to the inconsistency.
Failure to Facilitate Resident Transportation for PCP Visit
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not assisting a resident with transportation to her primary care physician (PCP), despite a physician's order for the visit. The resident, who had multiple diagnoses including seizures, dementia, major depressive disorder, congestive heart failure, COPD, hypertension, hypothyroidism, and hyperlipidemia, experienced ongoing symptoms such as shortness of breath, pain, and significant lower extremity edema. Progress notes documented repeated assessments and interventions by nursing staff and a nurse practitioner, including treatment for cellulitis and management of pain and respiratory symptoms. On the day of the scheduled PCP appointment, transportation was canceled, and the resident was unable to attend. The resident's sister attempted to arrange alternative transportation, but the resident was unable to get into a personal vehicle, leading the sister to call 911. The resident expressed a desire to go to the emergency room for evaluation of her symptoms, and the facility's nurse practitioner subsequently ordered a transfer to the ER. Prior to this, the facility's DON stated that the facility did not encourage outside PCP visits because their own medical staff could address resident needs, despite an existing order from the facility's medical director for the resident to see her PCP. Further review revealed that the LPN responsible for arranging transportation was unaware of the physician's order for the PCP visit. Ultimately, the resident was admitted to the hospital with diagnoses including weight gain, edema, and congestive heart failure. The failure to assist with transportation and facilitate the resident's choice to see her PCP constituted a lack of support for resident self-determination.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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